Provider Demographics
NPI:1205526092
Name:AMBAW, ABDUREZIK TEGABU
Entity type:Individual
Prefix:
First Name:ABDUREZIK
Middle Name:TEGABU
Last Name:AMBAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 HILLSDALE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95136-1113
Mailing Address - Country:US
Mailing Address - Phone:408-513-7154
Mailing Address - Fax:
Practice Address - Street 1:825 HILLSDALE AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95136-1113
Practice Address - Country:US
Practice Address - Phone:408-513-7154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health